Outbreak in Mexico May Be Smaller Than Feared

The swine flu outbreak in Mexico may be considerably smaller than originally feared, test results released there on Friday indicate.

Of 908 suspected cases that were tested, only 397 people turned out to have the virus, officially known as influenza A(H1N1), Mexican health officials reported at a news conference. Of those, 16 people have died.

Mexico had reported about 2,500 suspected cases as of Friday, but
the number of real cases could turn out to be less than half the
suspected number if further testing follows the same pattern as the
original round. Officials said that the tests were being done quickly,
and that 500 more would be completed Friday.

José Ángel Córdova, Mexico’s health minister, said, “This is a new
epidemic, and we can’t predict exactly” what it will do. “We need more
days to see how it behaves,” he said.

“Apparently the rate of infection is not as widespread as we might
have thought,” he added. The materials needed for the test were
provided to Mexico by the United States Centers for Disease Control and Prevention.

Officials at the centers declined to say what the new numbers might mean.

“We are continuously assessing new information, but it is still too
early to draw conclusions about the extent of the spread of this new
virus in Mexico or the severity of disease caused by it,” Dr. Nancy
Cox, chief of the influenza section, said by e-mail, when asked to
comment on the test results.

Dr. Javier Torres, the head of the infectious disease research unit at the Mexican Social Security Institute, Mexico’s main public health care system, said that he had been analyzing the past week’s influenza statistics.

“The number of those exposed and infected has gone up, and the
number of fatal cases has gone down,” he said. “We can be comfortable
with those facts.”

Officials at the World Health Organization,
which has declared that a pandemic is imminent, declined to comment
beyond saying that the investigation into the outbreak was continuing.

But a public health and infectious disease expert from Vanderbilt University,
Dr. William Schaffner, said the test results were “going to change, I
think in a substantial way, the image of this outbreak in Mexico.”

If the outbreak is much smaller than initially thought, Dr.
Schaffner said, “It would, I think, enable the world’s public health
community to take a deep breath and continue to track the outbreak and
reduce the tendency, as the W.H.O. has been doing, to notch up on its
pandemic scale.”

If the testing also shows that the disease has caused fewer deaths
than the 170 or so suspected, Dr. Schaffner said, it might resolve a
question that has been puzzling health experts since the outbreak
began: why did the disease appear to be so much more severe in Mexico
than in the United States? In the United States, cases have been mild
and there has been only one death, that of a 23-month-old child from
Mexico. Meanwhile, the disease continued to spread to other countries
and was confirmed in more American states on Friday. The disease is
expected to drop off during the summer, because flu
viruses do not thrive in heat and humidity, but it could rebound in the
fall and winter. The World Health Organization said that the flu
vaccine given to millions of people for the most recent flu season
appeared ineffective against the A(H1N1) strain, but that health
officials were talking to manufacturers about creating a new swine-flu vaccine, which would take four to six months to produce.

Dr. Marie-Paule Kieny, director of the Initiative for Vaccine
Research at the World Health Organization, said that unless the numbers
of cases decreased significantly, “it seems mostly likely that the
manufacturers will proceed and we will certainly support them.”

Officials at the Centers for Disease Control said a decision had not yet been made about whether to manufacture a vaccine, but President Obama said that the government would support it.

New cases were reported in Denmark, France, Russia, Hong Kong and
South Korea on Friday, but they were not confirmed by the health
organization. The United States reported 141 confirmed cases in 19
states, up from 109 cases in 11 states on Thursday.

Concerns about the disease are having an increasing impact. On Friday, a United Airlines
flight with 245 passengers heading from Munich to Dulles Airport in
Washington landed in Boston instead because a female passenger had flu
symptoms and the airline thought she needed prompt attention, a United
Airlines spokesman said.

In New York, the school with the nation’s largest cluster of swine
flu to date — St. Francis Preparatory School in Fresh Meadows, Queens —
was set to reopen Monday after being closed for a week.

Researchers say that some genetic features of the virus may help explain why many cases tend to be mild.

“We do not see the markers for virulence that were seen in the 1918
virus,” said Dr. Cox, of the Centers for Disease Control. “However, we
know there is a great deal we don’t understand about the virulence of
1918 or other viruses that have a more severe clinical picture in
humans.”

It is too early to know what economic impact, if any, the flu outbreak might have on the United States economy. The Congressional Budget Office
estimates that the recession will push this year’s national economic
output 7.5 percent below its potential level. A true flu pandemic could
shave off an additional 1 to 4.25 percent and could have a similar
effect on the world’s output, too, some economists say.

Denise Grady and Liz Robbins
reported from New York. Reporting was contributed by Larry Rohter and
Elisabeth Malkin from Mexico City, Keith Bradsher from Hong Kong, and
Anemona Hartocollis and Catherine Rampell from New York.

• Sustained human-to-human transmission has remained only in Mexico and USA, thereforephase 5 continues to be in effect.

• The World Health Assembly (WHA) is scheduled in Geneva as planned (18-27 May 2009).

• As of today, WHO has decided to refer to the virus as Influenza A/H1N1.

Status of the Region

• Mexico: 397 confirmed cases, including 16 deaths. There has been an increase in totalconfirmed cases in Mexico mostly due to testing of backlogged cases. At the same time, thenumber of probable cases appears to be decreasing in the Mexico City area.

• The United States: 160 confirmed cases, including 1 death.

• Canada: 70 confirmed cases; some with recent travel history to Mexico.

• Costa Rica: 1 confirmed case with recent travel history to Mexico.

• A daily epidemiological report is posted on the PAHO website1; updated epidemiologicalreports from Mexico can be found on the Dirección General de Epidemiología2.

*Deaths: 168 deaths in Mexico, 12 confirmed as swine flu. One confirmed in U.S., a nearly 2-year-old boy from Mexico who died in Texas.

**Confirmed sickened worldwide: 504; 300 confirmed
as having swine flu in Mexico; 133 in U.S.; 35 in Canada; 13 in Spain;
eight in Britain; four each in Germany and New Zealand; two in Israel;
one each in Switzerland, Austria, China, Denmark and the Netherlands.
Mexico is no longer releasing "suspected" numbers; the number of
suspected cases was 2,498 before the tally was halted.

**U.S. confirmed sickened, by state: 50 in New
York; 26 in Texas; 18 in California; 10 in South Carolina; five in New
Jersey; four each in Arizona and Delaware; two each in Kansas,
Colorado, Virginia, Michigan and Massachusetts; and one each in
Indiana, Ohio, Georgia, Minnesota, Nebraska and Nevada.

On Thursday, the swine flu outbreak caused schools in 14 states to shut their doors on more than 160,000 schoolchildren, and additional closures could affect as many as 223,700 students in 17 states.In total, more than 100 school systems have closed at least one school
as the nation tries to stifle the spread of the disease. In Texas
Wednesday night, officials announced that the entire Fort Worth school
system would be closed through at least May 8 as a precaution, idling
80,000 children in 140 schools.ABC News link

Below is the best North American map I've seen. It is the map from the Pan-American Health Organization -- which is the WHO region for the Americas. It doesn't contain some of the Central American and South America information, but it does provide a good overview of North America PAHO Flu Map link To see a larger version, just click on this map.

To date, the United States
has confirmed a total of 109 human cases of swine influenza A H1N1: 1
in Arizona, 14 in California, 1 in Indiana, 2 in Kansas, 2 in
Massachusetts, 1 in Michigan, 1 in Nevada, 50 in New York City, 1 in
Ohio, 10 in South Carolina and 26 in Texas. Other suspected cases are
being investigated. 5 hospitalizations and a death have been
registered. The dead case is a child of 22 months old, from Mexico who
died in a hospital of Houston, Texas area.

The most recent cases detected as well as the registered death
suggest that more serious cases could appear in the United States.

From 17 to 29 April, Mexico has reported 1,918
suspected cases of influenza with severe pneumonia including 84 deaths.
The suspected cases were recorded in all Mexican states. Most of them
in the Federal District, Guanajuato, State of Mexico, Aguascalientes,
Queretaro and San Luis Potosí. The majority of these have occurred in
previously healthy young adult people. There have been few cases in
individuals under 3 or over 59 years old. 933 of the suspected cases
are currently hospitalized.

The number of probable cases of swine influenza A H1N1 remains at
286, and a total of 97 cases has been confirmed. The considerable
variation in the number of confirmed cases as of today is due to the
recent laboratory confirmation of samples collected in previous weeks.
The number of confirmed dead cases remains at 7. This figure is also
subject to variations depending on the new laboratory information.

In Canada, to date 19 human cases of swine
influenza A H1N1 have been confirmed (2 in Alberta, 4 in the province
of New Scotland, 6 in British Columbia and 7 in Ontario) some of them
with recent trip history to Cancun, Mexico. All the cases developed a
mild form of influenza like illness. 2 of the cases presented, in
addition, gastrointestinal symptoms. All of them are currently
recovered and none required hospitalization. Laboratory tests were
conducted in Winnipeg, Canada. `Indigenous` transmission is not
discarded since not all the confirmed cases have trip history to Mexico.

The press has reported information on suspected cases in several
countries of the Region; however this information has not been
confirmed.

International Health Regulations (IHR)

At the request of the Director-General (DG) of WHO, the IHR
Emergence Committee has been summoned and is advising the DG on the
event. On its first day of deliberation, 25 April, it concluded that
the present event constitutes a Public Health Emergency of International Concern.

On 29 April 2009, the DG decided to elevate the pandemic alert to
Phase 5. In order to come to this urgent decision, the DG considered
epidemiological information from the most affected countries, as well
as the result of the scientific meeting held that same day. The latter
indicated existence of sustained outbreaks of swine influenza A H1N1 at
the community level in more countries within the Region.

The decision to increase the pandemic level of the alert should
permit Member States to provide the required leadership and
coordination as well as to consider the possibility of executing their
contingency plans.

The DG recommends not closing borders or restricting travel.
However, it is prudent for people who are sick to delay travel.
Moreover, returning travelers who have become sick should seek medical
attention in line with guidance from national authorities.

Production of seasonal vaccine should continue, but at the same
time, WHO is making all the efforts to facilitate the process of
development of a vaccine against swine influenza A H1N1.
The Committee will continue to advise the DG on the basis of the available information.

Recommendations

Enhanced surveillance

At this time, enhanced surveillance is recommended. On its Web page,
PAHO has published orientations for the enhancement of surveillance
activities, which are directed to the investigation of:

Clusters of cases of ILI/SARI of unknown cause

Severe respiratory disease occurring in one or more health workers

Changes in the epidemiology of mortality associated with ILI/SARI;
increase of observed deaths by respiratory diseases; or increase of the
emergence of severe respiratory disease in previously healthy
adults/adolescents.

Persistent changes observed in the response to the treatment or evolution of a SARI.
The following risk factors should also cause suspicion of swine influenza A H1N1 virus:

Close contact with a confirmed case of swine influenza A H1N1 while the case was sick.

Recent travel to an area where there are confirmed cases of swine influenza A H1N1 have been confirmed

Virological surveillance of swine influenza A H1NI

It is recommended that National Influenza Centers (NIC) immediately
submit to the WHO Collaborating Center for influenza (CDC of the United
States) all positive but unsubtypable specimens of influenza A.
Shipment procedures are the same as those used by NICs for seasonal
influenza specimens.

The test protocols for the detection of seasonal influenza by
Polymerase Chain Reaction (PCR) cannot confirm swine influenza A H1N1
cases. The Centers for Disease Control and Prevention of the United
Sates are preparing testing kits that will include the primers and
probes as well as the required positive control samples. The kits will
be sent in the first week of May to those NICs that currently use the
CDC protocol.

Infection prevention and control in health care facilities

Since the main form of transmission of this disease is by droplets
it is recommended strengthening the basic precautions to prevent their
dissemination, for example the hygiene of hands, adequate triage in the
health facilities, environmental controls, and the rational use of the
personal protective equipment in accordance with the local regulations.

I admit that there are enormous information asymetries between the CDC and me -- as well as an enormous difference in expertise. I have been worried that CDC was moving too slowly -- perhaps because it has never dealt with a pandemic within institutional memory and perhaps because the White House is worried about the impact that pandemic precautions will have on the economic situation (assuming that this is a false alarm - and the flu does not spread or it remains milder than the Mexico strain). The CDC's actions seem consistent with the WHO analysis that we cannot contain the international spread of the disease -- the cat is out of the bag, the horse is out of the barn -- and all we can do is mitigate and ride out whatever this disease has in store for us.

It is gratifying to see that the US supply of Tamiflu is up to 50 million courses. That's enough to cover 15% of the population, though a tad short of the 25% goal that the federal government set. Together with the available supplies in state and local government stores, corporate stores, and health care provider supplies, it looks like there is a good chance that there is enough Tamiflu in the US to cover any probable outbreak of swine flu.

The virulence of the flu is still a question mark. No one has convincingly indicated why the Mexico experience is so much different. Certainly, there appears to be rapid human-human transmission, but most cases outside Mexico have been mild. Even so, the CDC is not placing much weight on the mild illness manifested to date in the US. In Dr. Besser's words, the CDC expects a full spectrum of disease to occur -- meaning serious illness and some deaths in the U.S.

The death toll in Mexico is reportedly about 10%, which is vastly more virulent than the 1918 flu, which killed between 20 - 50 million people (including my paternal grandmother) and reduced global domestic product between 2.4 - 16.9%. That flu killed roughly 2% of its victims, which were dominantly young, healthy adults -- the Mexico flu has killed 10% of its victims, again dominantly young, healthy adults. At that rate, we could see more than 50 million deaths with this flu if it spirals out of control. But then again, we can't simply extrapolate from the current "kill rate" because that likely reflects the most serious illnesses, not the norm.

So what should a responsible community in an unaffected state do at this point? My community, for example.

To begin an analysis of what communities should be doing, start with the pandemic severity index. Based on current data from Mexico, the case/fatality ratio appears to be Category 5. However, based on current data (admittedly still sparse from the US), the ratio has been category 1. It increased to category 4 with the first death, but has fallen back to category 3 as more confirmed cases occur in the US without additional deaths (4/29 and 4/30 update) Since CDC and WHO have still not explained the difference in ratio between genetically identical viruses, one could simply split the difference and call this a category 3 pandemic. However, since the good results in the US seem attributable to rapid treatment with effective anti-viral drugs and anti-viral supplies may not remain sufficient to treat everyone who is infected or at high risk due to close contact with infected persons, it might be prudent to treat this as a category 4 pandemic.

While there are 50 million courses in the US stock, that only covers roughly 17% of the US population with a single treatment. Preventative treatment for those in health care and public safety positions who are frequently exposed will consume up to 15 million of those courses, reducing treatment coverage down to about 12%. Assuming that both US stocks and other stocks held by state and local governments, health providers, and corporations are used only to treat the seriously ill, that should be enough for the first wave. But, the second or third waves, perhaps next fall before a vaccine is available, will be met with insufficient stores of anti-viral drugs and the virus may mutate to become resistant to the current drugs. So, it would seem wise to depend on non-pharmaceutical approaches to reduce disease incidence and conserve treatment course. In other words, to use community mitigation measures to increase social distancing so that we can contain the virus outbreaks without everyone getting exposed and a bunch of people needing treatment. (4/30 update)

It is this uncertainty that has led CDC to issue interim guidance on community mitigation because previous planning had been done based on the PSI categories

The next question is when should we act? That depends upon the WHO
phase/US stage. Note that the WHO phase has been declared at a phase 5. The US stage should be considered a stage 5 (cases spread throughout the US). That means that all of the
measures in the plan should be activated now. I can only speculate why
the WHO and US CDC are moving more slowly -- perhaps because they
believe that no one can react more rapidly. As of 4/30, it appears to me that all states, even unaffected states, are implementing their pandemic response plans. Still a day or two late and a dollar short.

But, assuming a Category 3 or 4 PSI pandemic is occurring and that we are at stage 5, what should happen? It seems to me that all of the community mitigation measures and interventions in category 4,5 should be recommended except that I would close schools for a week (and depending upon events up to 4 weeks) at this time rather than up to 12 weeks.If you click on the image below, you will be able to read the recommended measures in a separate window.

4/29 PM update

Even a day makes a difference! WHO is now considering increasing its phase to Phase 5. The US now has a death rate that exceeds 1%, so the Pandemic Severity Index in the US is a Category 4 severity, especially given the death rate in Mexico which appears to be in excess of 2% and thus a Category 5 severity. So NOW would be the time to begin all of those community mitigation efforts in every affected state....and at least most of them throughout the US.

4/30 update

It seems as though state and local governments are now acting aggressively to close schools whenever a probable case is identified. That appears to be an adequate response. In Oregon, state officials have suggested that closures will be for about a week -- which is enough time for exposed students to become symptomatic, seek treatment, and be diagnosed as probable cases (although not confirmed). Response seems to be catching up to the situation.

Colorado health officials
said Wednesday they were awaiting test results for what they called
five suspected cases of swine flu. Thursday morning, they announced 2
cases have been confirmed. The 2 confirmed cases are in Arapahoe and Douglas counties.News link

WHO Update 6 added the Netherlands to the list of countries, with one confirmed case. The cases from Costa Rica and Peru have not yet been reported to WHO. The additional New Zealand cases have not yet been reported to WHO. WHO's Canadian count has jumped from 13 to 19. WHO's UK count has increased from 5 to 8. The total count of confirmed cases reported to WHO is now 257.

Thursday, April 30th early AM Update

There's so much to take in that the PM update has become an early AM update.

WHO has not published another update on international reported, confirmed cases. Based on news reports, confirmed
cases include Austria (1), Canada (13), Germany (3), Israel (2), New
Zealand
(14), Spain (10), the United Kingdom (5), Costa Rica (2) and Peru(1). In both New Zealand and Spain, there are large numbers of suspected cases that have not yet been confirmed.

Wednesday, April 29th AM Update

WHO has announced reported confirmed cases in 9 nations; a total of 148 reported confirmed cases; in addition to US and Mexico, confirmed cases include Austria (1), Canada (13), Germany (3), Israel (2), New Zealand
(3), Spain (4) and the United Kingdom (5). The US has reported 91 confirmed cases and 1 death, currently providing a case/fatality ratio of just over 1%. Mexico has reported 26 confirmed cases and seven deaths. That would be a case/fatality ratio over 25%, however, the vast bulk of Mexican cases and deaths have not yet been reported and confirmed. Assuming the number of suspected cases (2517 with 159 suspected deaths) turn out to be accurately identified, this provides a case/fatality ratio of 6+%. That is about 3 times as deadly as the 1918 Spanish flu pandemic, which killed 20- 40 million people. Fortunately, we have large quantities of anti-viral drugs and have been planning for this event for several years now, so deaths should be extremely limited.

Tuesday April 28th update (PM):

According to AP, the confirmed Canadian cases now number 13, rather than six. AP report Both Spain and Israel now have 2 confirmed cases according to WHO, with WHO reporting 2 confirmed New Zealand cases and 2 confirmed UK cases, rather than the 3 NZ cases previously reported..

Denmark, Columbia, Czech Republic, Australia, and Russia have joined the list of countries with suspected cases.

Tuesday April 28th update (AM):

Israel and New Zealand have confirmed cases. Switzerland added to suspected case list .Washington Post link The Washington Post has a nice map, but it only tracks North American cases. WP map The New York Times has a global map showing both confirmed and suspected cases. NYT graphic However, both of the maps are lagging behind -- the NYT didn't pick up the 3 confirmed New Zealand cases or the suspected cases in the EU.

There have been six lab-confirmed cases of mild swine flu in Canada
and one in Spain, which became the first country in Europe to confirm a
case after a man who returned from a trip to Mexico last week was found
to have the virus. Spain has 26 suspected cases under observation
and a New Zealand teacher and a dozen students who recently travelled
to Mexico are being treated as likely mild cases Countries
including Australia, France, Germany, Norway, Sweden, Israel,
Guatemala, Costa Rica and South Korea are all testing suspected cases
of the flu. In the first confirmed cases in Britain, Scotland's health minister says two people tested positive for swine flu.

The Scottish cases bring the number of nations with confirmed cases to five and the number of nations with suspected cases to 14.

In
response to an intensifying outbreak in the United States and
internationally caused by a new influenza virus of swine origin, the
World Health Organization raised the worldwide pandemic alert level to Phase 5
on April 29, 2009. A Phase 5 alert is a “strong signal that a pandemic
is imminent and that the time to finalize the organization,
communication, and implementation of the planned mitigation measures is
short.”

The United States Government has
declared a public health emergency in the United States. CDC’s response
goals are to reduce transmission and illness severity, and provide
information to help health care providers, public health officials and
the public address the challenges posed by this emergency. CDC is
issuing and updating interim guidance
daily in response to the rapidly evolving situation. CDC’s Division of
the Strategic National Stockpile (SNS) continues to send antiviral
drugs, personal protective equipment, and respiratory protection
devices to all 50 states and U.S. territories to help them respond to
the outbreak. The swine influenza A (H1N1) virus is susceptible to the
prescription antiviral drugs
oseltamivir and zanamivir. In addition, the Federal Government and
manufacturers have begun the process of developing a vaccine against
this new virus.

As the swine flu
virus appeared in new locations as far apart as Peru and Switzerland on
Thursday, Mexicans braced for a national shutdown of offices,
restaurants, schools and even the stands of soccer stadiums in an
attempt to slow the spread of the disease. In nationally televised speech on Wednesday night, the Mexican president, Felipe Calderón,
said that many public services would be closed Friday through Tuesday,
encompassing a long holiday weekend. Most government offices and many
private businesses will be ordered closed, restaurants, schools and
museums will remain shuttered, and spectators will be barred from all
professional soccer matches.Churches are expected to be nearly empty on Sunday.

...in Mexico, the epicenter of the disease, Mr. Calderón urged much
broader precautions [than those being taken in Britain]. People should stay inside their homes during the
holiday hiatus, he said, and the shutdown and restrictions could
possibly be extended further into next week. The Mexican minister of health, Jose Cordova, said all nonessential
federal services will shut down, and Mexico City extended the federal
ban to include health clubs, gyms, museums and movie theaters.Police stations, airports, bus stations and the capital’s subway
system were to remain open under the federal plan, along with banks,
food stores, pharmacies and gasoline stations.

Some 2,500 Mexicans have been sickened since the swine flu outbreak
began last week in the town of La Gloria, 110 miles east of Mexico
City. Mexico has reported just 99 confirmed cases of swine flu to the
W.H.O., along with eight deaths, although as many as 168 people are
suspected to have died from the disease there.

Contrast this reaction with that of NYC:

The number of swine flu cases in New York City
continues to grow, with hundreds of confirmed or suspected cases mostly
among students. Four schools - two in Brooklyn and two in Queens
- will be closed for the rest of the week to prevent any further spread
of this new variant of influenza. But with only one reported death and
few reports of severe illness in the U.S. attributed to swine flu, New
Yorkers are mostly brushing off worries about the illness.

Anna Garcia and daughter

The
number of swine flu cases has been growing, but New York seems more
like a city under the spell of spring weather rather than worried about
a possible pandemic. Parents, students and workers say they're
watchful, but not alarmed. Letia Frandino is from the borough
of Queens, where the New York outbreak was first detected, says this is
the reason why she paid closer attention to the alert: "... because it
was in Queens. I have heard that we shouldn't be panicking because
there are still mild cases so far in the United States, so that's what
we are going on," she said. Anna Garcia, picking up her daughter
after school, said she's also not worried. "I'm a public school teacher
in Brooklyn, in a community that's mostly from Mexico, and they don't
seem to be panicking. And as long as you keep your hands clean," she
says, "you tell the children to keep, you know, like you would any cold
or flu, you're just telling them to protect themselves." Students
doing homework at a park in Manhattan said they've been warned at
school about what could happen if swine flu emerges there. One student,
Alison, says, "They were saying how all the kids would miss school for
two days while they cleaned the whole school, and the kids would have
to go to doctors." Student Jonathan adds, "No one really wears masks,
like they're not afraid, it's just the flu. But they don't know how bad
it is, maybe?"

Michael Bloomberg

On
Tuesday, New York Mayor Michael Bloomberg said swine flu is expected to
spread around the city - as some form of influenza does each year - but
that, for now, it does not look as if it will cause more deaths than
other flus. "From what we know now, swine flu seems to spread
similarly to seasonal garden-variety flu, that we regularly see in our
city and we have no reason at the moment from what we have seen here to
believe its symptoms are any more severe," he said. The mayor said that people with flu should stay home, but that no one in New York has yet become seriously ill.

"Almost
every case has been very mild," Bloomberg said. "And the process of
going from catching it to noticeably getting better, has been in a few
days, very quick." That may be why New Yorkers don't appear worried, and subway cars are as jammed as ever, with few people wearing masks. "What can you do?" one man said. "You have to get around. Wash your hands, just be careful what you do."

The difference in New York City and Mexico City is not a difference in the virus. It is a difference in the length of time that the virus has been active and a difference in the level of government response. Time will tell which response is more appropriate -- but I'd prefer that the government follow the precautionary principle and err on the side of caution. The federal government seems to be doing that, but most of the decisions about community mitigation measures are in the hands of the state and local governments, not the federal government. With uneven response, the likelihood that everyone in the United States will get an opportunity to be exposed to this flu is high.

WHO and health authorities in affected countries will not have all the answers immediately, but we will get them.

WHO will be tracking the pandemic at the epidemiological, clinical, and virological levels.

The results of these ongoing assessments will be issued as public health advice, and made publicly available.

All countries should immediately activate their pandemic preparedness
plans. Countries should remain on high alert for unusual outbreaks of
influenza-like illness and severe pneumonia.

At this
stage, effective and essential measures include heightened
surveillance, early detection and treatment of cases, and infection
control in all health facilities.

This change to a higher
phase of alert is a signal to governments, to ministries of health and
other ministries, to the pharmaceutical industry and the business
community that certain actions should now be undertaken with increased
urgency, and at an accelerated pace.

I have reached out to donor countries, to UNITAID, to the GAVI Alliance, the World Bank and others to mobilize resources.

I have reached out to companies manufacturing antiviral drugs to assess capacity and all options for ramping up production.

I have also reached out to influenza vaccine manufacturers that can contribute to the production of a pandemic vaccine.

The biggest question, right now, is this: how severe will the pandemic be, especially now at the start?

It is possible that the full clinical spectrum of this disease goes
from mild illness to severe disease. We need to continue to monitor the
evolution of the situation to get the specific information and data we
need to answer this question.

From past experience, we also
know that influenza may cause mild disease in affluent countries, but
more severe disease, with higher mortality, in developing countries.

No matter what the situation is, the international community should
treat this as a window of opportunity to ramp up preparedness and
response.

Above all, this is an opportunity for global
solidarity as we look for responses and solutions that benefit all
countries, all of humanity. After all, it really is all of humanity
that is under threat during a pandemic.

As I have said, we do not have all the answers right now, but we will get them.

I haven't tried to find out other blog and website traffic figures, but based on my figures, swine flu "sells." This might be a good time to remind readers that all royalties from this blog go to fund water and sanitation projects in developing countries, not my extravagant lifestyle! The traffic since Sunday has exceeded the highest traffic since I began the blog three years ago. Yet only about half of the traffic overall involves swine flu.

I saw the news from the Commerce Department today that the US economy contracted at a 6.1% annual rate during the first quarter of this year following a 6.3% loss in GDP during the fourth quarter of 2008. A quick glance at the CRS report on recessions indicates that no post WWII recession had two quarters of consecutive reductions in GDP in the 6+% range. This is a much steeper recession than anything in the past.

For those of you who try to stay current on science policy, I am a member of AAAS and receive its policy alerts. I encourage all of you to join and subscribe to Science. Here is today's policy alert:

AAAS Policy Alert -- April 29, 2009

President Addresses National Academies

President Obama addressed the Annual Meeting of the National Academy of Sciences
on April 27 and called for a renewed commitment to basic scientific
research and education. During his speech he stated that his goal would
be to increase our nation's share of federal investment in research and
development (R&D) to 3 percent of gross domestic product (GDP). In
recent years, the share has hovered around 2.6 percent of GDP.
Furthermore, Obama announced the
membership of the President's Council of Advisors for Science and
Technology (PCAST). Members include past AAAS President Shirley Ann
Jackson of RPI, as well as former Board member Rosina Bierbaum and
current AAAS Treasurer David Shaw. They join former AAAS President John
Holdren who is both the U.S. President's science advisor and co-chair
of PCAST.

Budget News

The
House and Senate have nominated the conferees to resolve the
differences between their respective versions of the FY 2010 budget
resolution. House members include: Budget Committee Chairman John
Spratt (D-SC), Ranking Member Paul Ryan (R-WI), and Reps. Allen Boyd
(D-FL), Rosa DeLauro (D-CT) and Jeb Hensarling (R-TX). Senate members
include Budget Committee Chair Kent Conrad (D-ND), Ranking Member Judd
Gregg (R-NH) and Sen. Patty Murray (D-WA). The conferees met today
(April 27) to begin deliberating over a consensus document.

Other Congressional News

Congressional Climate Change Update. The House Energy and Commerce Committee held four days of hearings
on the American Clean Energy and Security Act, with much debate on the
merits of moving ahead on the climate and energy package. Subcommittee
markup of the bill has been pushed back to next week, with details such
as how to allocate permits to emit greenhouse gases and how the
revenues will be used yet to be determined. Meanwhile Senate
Environment and Public Works Chairwoman Barbara Boxer (D-CA) announced
the formation of five working groups
to find compromises in several areas of concern: regional issues, cost
containment, targets and timetables, market oversight and coal research
and technology. The Senate Foreign Relations Committee
heard from Todd Stern, special envoy for climate change at the State
Department, who testified on the diplomatic cost of inaction on climate
change and emphasized the need for all countries - developed and
developing - to engage in negotiations with "common but differentiated
responsibilities." Stern is leading the first session of the Major Economies Forum on Energy and Climate
on April 27-28, a White House initiative to develop a dialogue among
major developed and developing economies on climate change.

New Bill Promotes Science Envoys. Last week, Senator Richard Lugar (R-IN) introduced legislation (S. 838)
that recognizes the importance of international scientific cooperation
and the work of organizations such as AAAS and the National Academies
in this area. The legislation tasks the State Department to appoint
Science Envoys to represent our nation and promote international
collaboration.

Executive Branch

Presidential Memo on Scientific Integrity. OSTP issued a Presidential Memo on scientific integrity in the April 23 Federal Register
and requests public comments on six principles for maintaining and
protecting the responsible use of science in decision-making. The memo
builds upon a March 9, 2009 memorandum from the President that called
on OSTP to issue a set of recommendations within 120 days. OSTP has
launched a blog
on the subject and is seeking comments on the selection of scientists
to serve in the executive branch, peer-review of science used in
policy-making, access to scientific data used in policy-making, and
whistleblower protection. Comments are due May 13, 2009.

NIH Stem Cell Guidelines Now Open for Comment. The NIH Guidelines for Human Stem Cell Research are now open for public comment until May 26.

NCI Director Speaks on Cancer Plan. National Cancer Institute Director John Niederhuber recently spoke of his institute's plans
in the wake of President Obama's cited goal of doubling funds for
cancer research. Included would be a boost in the NCI payline to fund
more meritorious research grants, as well as more grants to first-time
investigators and new faculty researchers. There will also be a focus
on personalized cancer care.

EPA Examines Ocean Acidification. On April 14, EPA issued a Federal Register notice
requesting information on ocean acidification, the changing of ocean
chemistry from increases in carbon dioxide that affects coral reefs and
other marine organisms. In response to a lawsuit by the Center for
Biological Diversity, EPA is trying to determine whether changes are
needed to the water quality criteria under the Clean Water Act.
Comments are due June 15, 2009.

Toxics Reporting Tightened. As mandated in the 2009 omnibus appropriations bill, EPA finalized changes to reporting requirements under the Toxics Release Inventory
that will take effect July 1. The final rules restore more stringent
reporting requirements than those from a Bush-era rule that raised the
pollution threshold for reporting. In 2006, AAAS submitted comments
stating that the increased threshold would "threaten the ability of
researchers to identify and understand potential threats to the
environment and public health in a scientifically rigorous manner."

FDA Widens Access to "Morning-After" Pill.
The Food and Drug Administration will now allow 17-year-olds to
purchase the Plan B "morning-after" pill without a prescription,
following a recent federal court order that it do so. The decision has
been labeled a "triumph of science over politics"
because of widespread concern that the previous administration
overruled scientific advice on making the pill available over the
counter, leading the FDA's top women's health official, Susan Wood, to resign in protest in 2005.

Nation's First CTO: Clarification. Last week's Policy Alert reported on the President's selection of Aneesh Chopra to be the nation's first chief technology officer. It has since been reported
that the CTO will also be one of the associate directors of the Office
of Science and Technology Policy (OSTP) concerned with overall
technology policy and innovation strategies across federal departments.
Chopra's position (which is subject to Senate confirmation) should not
be confused with that of Vivek Kundra, recently named Chief Information
Officer, who is located in the Office of Management and Budget (OMB),
overseeing day-to-day information technology spending and interagency
operations.

Elsewhere

Climate Risk Report Released.
Led by the Heinz Center and CERES, a coalition of insurance,
government, environmental, and investment organizations released a
report, Resilient Coasts: A Blueprint for Action that listed steps the nation can take to drastically reduce rising coastal hazard risks and their associated economic impacts.

Texas School Board Chairman Up for Confirmation.
Texas State Board of Education Chairman Don McLeroy, a vocal opponent
of teaching evolution, is up for Senate confirmation by the state
Senate, and during a recent hearing
some members of the Senate Nominations Committee expressed
dissatisfaction with McLeroy's performance. One state senator said
McLeroy has "created a hornet's nest" and noted that 15 bills filed
during this legislative session would strip powers from the state
school board. Even if McLeroy is not confirmed as chairman, he will
still remain a member of the board. In other news, the Institute for
Creation Research is now suing in U.S. District Court over the Texas
Higher Education Coordinating Board's decision to deny its request to
offer a master's degree in science education.

Animal Rights Activists Charged. Two animal rights activists have been arraigned on
charges of conspiracy, stalking and other crimes, including attempted
fire-bombing, against UCLA scientists engaged in animal research.

NOTE: The AAAS Policy Alert is a newsletter provided to AAAS Members to
inform them of developments in science and technology policy that may
be of interest. Information in the Policy Alert is gathered from
published news reports, unpublished documents, and personal
communications. Although the information contained in this newsletter
is regarded as reliable, it is provided only for the convenience and
private use of our members. Comments and suggestions regarding the
Policy Alert are welcome. Please write to alert@aaas.org.

The Mexican swine flu virus is a swine influenza A/H1N1 virus hybridized (mixed) with human and bird viruses. We have some immunity to human flu and to some strains of swine influenza A/H1N1; We don't have immunity to bird flu, which is why that virus is so virulent - with a kill ratio of almost 50% -- and why so much pandemic planning and preparedness focused on bird flu.

This type of virus emerged in the
US in 1998 and has since become endemic on hog farms across North
America. Equipped with a suite of pig, bird and human genes, it was
also evolving rapidly. Flu
infects many animals, including waterfowl, pigs and humans. Birds and
people rarely catch flu viruses adapted to another host, but they can
pass flu to pigs, which also have their own strains.If a pig catches
two kinds of flu at once it can act as a mixing vessel, and hybrids can
emerge with genes from both viruses. This
is what happened in the US in 1998. Until then, American pigs had
regular winter flu, much like people, caused by a mutated virus from
the great human pandemic of 1918, which killed pigs as well as at least
50 million people worldwide. This virus was a member of the H1N1 family
- with H and N being the virus's surface proteins haemagglutinin and
neuraminidase. Over
decades, H1N1 evolved in pigs into a mild, purely swine flu, and became
genetically fairly stable. In 1976, there was an outbreak of swine H1N1
in people at a military camp [Fort Dix] in New Jersey, with one death. The virus
did not spread efficiently, though, and soon fizzled out.

But in 1998, says Richard Webby
of St Jude's Children's Research Hospital in Memphis, Tennessee, swine
H1N1 hybridised with human and bird viruses, resulting in "triple reassortants"
that surfaced in Minnesota, Iowa and Texas. The viruses initially had
human surface proteins and swine internal proteins, with the exception
of three genes that make RNA polymerase, the crucial enzyme the virus
uses to replicate in its host. Two were from bird flu and one from
human flu. Researchers believe that the bird polymerase allows the
virus to replicate faster than those with the human or swine versions,
making it more virulent.

By
1999, these viruses comprised the dominant flu strain in North American
pigs and, unlike the swine virus they replaced, they were actively
evolving. There are many versions with different pig or human surface
proteins, including one, like the Mexican flu spreading now, with H1
and N1 from the original swine virus. All these viruses still contained the same "cassette" of internal genes, including the avian and human polymerase genes, reports Amy Vincent of the US Department of Agriculture (USDA) in Ames, Iowa (Advances in Virus Research, vol 72, p 127). "They are why the swine versions of this virus easily outcompete those that don't have them," says Webby.

But
the viruses have been actively switching surface proteins to evade the
pigs' immunity. There are now so many kinds of pig flu that it is no
longer seasonal. One in five US pig producers actually makes their own
vaccines, says Vincent, as the vaccine industry cannot keep up with the
changes. This
rapid evolution posed the "potential for pandemic influenza emergence
in North America", Vincent said last year. Webby, too, warned in 2004
that pigs in the US are "an increasingly important reservoir of viruses
with human pandemic potential". One in five US pig workers has been
found to have antibodies to swine flu, showing they have been infected,
but most people have no immunity to these viruses.

The virus's rapid evolution created the potential for a pandemic to emerge in North America. Our
immune response to flu, which makes the difference between mild and
potentially lethal disease, is mainly to the H surface protein. The
Mexican virus carries the swine version, so the antibodies we carry to
human H1N1 viruses will not recognise it. That's why the CDC warned last year that swine H1N1 would "represent a pandemic threat" if it started circulating in humans. The
avian polymerase genes are especially worrying, as similar genes are
what make H5N1 bird flu lethal in mammals and what made the 1918 human
pandemic virus so lethal in people. "We can't yet tell what impact they
will have on pathogenicity in humans," says Webby. It
appears the threat has now resulted in the Mexican flu. "The triple
reassortant in pigs seems to be the precursor," Robert Webster, also at
St Jude's, told New Scientist.

While
researchers focused on livestock problems could see the threat
developing, it is not one that medical researchers focused on human flu
viruses seemed to have been aware of. "It was confusing when we looked
up the gene sequences in the database," says Wendy Barclay of Imperial
College London, who has been studying swine flu from the recent US
cases. "The polymerase gene sequences are bird and human, yet they were
reported in viruses from pigs."

So where did the Mexican virus originate? The Veratect Corporation
based in Kirkland, Washington, monitors world press and government
reports to provide early disease warnings for clients, including the
CDC. Their first inkling of the disease was a 2 April report of a surge
in respiratory disease in a town called La Gloria,
east of Mexico City, which resulted in the deaths of three young
children. Only on 16 April - after Easter week, when millions of
Mexicans travel to visit relatives - reports surfaced elsewhere in the
country.

Local reports in La Gloria blamed pig farms in nearby Perote owned by Granjas Carroll, a subsidiary of US hog giant Smithfield Foods. The farms produce nearly a million pigs a year. Smithfield Foods, in a statement,
insists there are "no clinical signs or symptoms" of swine flu in its
pigs or workers in Mexico. That is unsurprising, as the company says it
"routinely administers influenza virus vaccination to swine herds and
conducts monthly tests for the presence of swine influenza." The
company would not tell New Scientist any more about recent
tests. USDA researchers say that while vaccination keeps pigs from
getting sick, it does not block infection or shedding of the virus.

All
the evidence suggests that swine flu was a disaster waiting to happen.
But it got little research attention, perhaps because it caused mild
infections in people which didn't spread. Now one swine flu virus has
stopped being so well-behaved.

This leads us to the policy question: why should humans keep pigs? Like other meat, pigs consume an extraordinary amount of resources to provide nutrition. Maybe the ancient Israelites had an insight that we have lacked -- there may be more wisdom in the Torah and its laws than we knew. Perhaps it is time, or past time, for our eating habits to evolve lest an even more virulent strain of swine flu develop. Assuming that this pandemic passes without too many deaths, we may need to rethink whether it is good to keep large quantities of pigs. For now, the virulent bird flu does not seem easily communicable. Let's keep it that way.

29 April 2009 --
The situation continues to evolve
rapidly. As of 18:00 GMT, 29 April 2009, nine countries have officially
reported 148 cases of swine influenza A/H1N1 infection. The United
States Government has reported 91 laboratory confirmed human cases,
with one death. Mexico has reported 26 confirmed human cases of
infection including seven deaths.

The
following countries have reported laboratory confirmed cases with no
deaths - Austria (1), Canada (13), Germany (3), Israel (2), New Zealand
(3), Spain (4) and the United Kingdom (5).

The
outbreak of disease in people caused by a new influenza virus of swine
origin continues to grow in the United States and internationally.
Today, CDC reports additional confirmed human infections,
hospitalizations and the nation’s first fatality from this outbreak.
The more recent illnesses and the reported death suggest that a pattern
of more severe illness associated with this virus may be emerging in
the U.S. Most people will not have immunity to this new virus and, as
it continues to spread, more cases, more hospitalizations and more
deaths are expected in the coming days and weeks.

CDC has implemented its emergency response.
The agency’s goals are to reduce transmission and illness severity, and
provide information to help health care providers, public health
officials and the public address the challenges posed by the new virus.
Yesterday, CDC issued new interim guidance
for clinicians on how to care for children and pregnant women who may
be infected with this virus. Young children and pregnant women are two
groups of people who are at high risk of serious complications from
seasonal influenza. In addition, CDC’s Division of the Strategic
National Stockpile (SNS) continues to send antiviral drugs, personal
protective equipment, and respiratory protection devices to all 50
states and U.S. territories to help them respond to the outbreak. The
swine influenza A (H1N1) virus is susceptible to the prescription antiviral drugs
oseltamivir and zanamivir. This is a rapidly evolving situation and CDC
will provide updated guidance and new information as it becomes
available.